Prevention and control of healthcare-associated infections

About

What is covered

This pathway covers the prevention and control of healthcare-associated infections in primary, community and secondary care.

Healthcare-associated infections can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting. Healthcare-associated infections can exacerbate existing or underlying conditions, delay recovery and adversely affect quality of life.

Healthcare-associated infections are caused by a wide range of microorganisms. The most well known include those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. diff) and Escherichia coli (E. coli).

Patient safety has become a cornerstone of care in the NHS, and preventing healthcare-associated infections remains a priority. Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year, £56 million of which is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient discomfort and a decrease in patient safety. A 'no tolerance' attitude is now prevalent in relation to avoidable healthcare-associated infections.

Surgical site infections

Surgical site (wound) infection occurs when pathogenic organisms multiply in a surgical wound, giving rise to local signs and symptoms, such as heat, redness, pain and swelling, and (in more serious cases) with systemic signs of fever or a raised white blood cell count. Infection in the surgical wound may prevent healing taking place so that the wound edges separate, or it may cause an abscess to form in the deeper tissues.

Surgical site infections comprise up to 20% of all healthcare-associated infections. At least 5% of patients undergoing surgery develop a surgical site infection. Surgical site infections can have a significant effect on quality of life for the patient, and are associated with considerable morbidity and extended hospital stay. Surgical site infections also result in a considerable financial burden to healthcare providers. The majority of surgical site infections are preventable and measures can be taken in the preoperative, intraoperative and postoperative phases of care to reduce risk of infection.

Use of 'must' in recommendations

There is a legal duty to implement some of the recommendations in this pathway in order to comply with legislation. The word 'must' is used in these recommendations and details of the relevant legislation are given in footnotes. In addition, 'must' is used in some other recommendations on patient safety where the consequences of not implementing them would be very serious – that is, there would be a greatly increased risk of adverse events, including death.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.

Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

This pathway covers the prevention and control of healthcare-associated infections in primary, community and secondary care.

What is covered

This pathway covers the prevention and control of healthcare-associated infections in primary, community and secondary care.

Healthcare-associated infections can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting. Healthcare-associated infections can exacerbate existing or underlying conditions, delay recovery and adversely affect quality of life.

Healthcare-associated infections are caused by a wide range of microorganisms. The most well known include those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. diff) and Escherichia coli (E. coli).

Patient safety has become a cornerstone of care in the NHS, and preventing healthcare-associated infections remains a priority. Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year, £56 million of which is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient discomfort and a decrease in patient safety. A 'no tolerance' attitude is now prevalent in relation to avoidable healthcare-associated infections.

Surgical site infections

Surgical site (wound) infection occurs when pathogenic organisms multiply in a surgical wound, giving rise to local signs and symptoms, such as heat, redness, pain and swelling, and (in more serious cases) with systemic signs of fever or a raised white blood cell count. Infection in the surgical wound may prevent healing taking place so that the wound edges separate, or it may cause an abscess to form in the deeper tissues.

Surgical site infections comprise up to 20% of all healthcare-associated infections. At least 5% of patients undergoing surgery develop a surgical site infection. Surgical site infections can have a significant effect on quality of life for the patient, and are associated with considerable morbidity and extended hospital stay. Surgical site infections also result in a considerable financial burden to healthcare providers. The majority of surgical site infections are preventable and measures can be taken in the preoperative, intraoperative and postoperative phases of care to reduce risk of infection.

Use of 'must' in recommendations

There is a legal duty to implement some of the recommendations in this pathway in order to comply with legislation. The word 'must' is used in these recommendations and details of the relevant legislation are given in footnotes. In addition, 'must' is used in some other recommendations on patient safety where the consequences of not implementing them would be very serious – that is, there would be a greatly increased risk of adverse events, including death.

Personal preparation for surgery

Quality statement

People having surgery are advised not to remove hair from the surgical site and are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery.

Rationale

It is not necessary to remove hair routinely to reduce the risk of surgical site infection, and the use of razors for hair removal may increase the risk of infection. If hair needs to be removed, this should be done by healthcare staff using electric clippers with a single-use head on the day of surgery. Pre-operative showering is likely to reduce the number of microorganisms on the skin surrounding the incision and may therefore reduce the risk of infection. Pre-operative advice (and assistance if needed) on personal preparation for surgery will help to ensure that people having surgery have clean skin without unnecessary micro-abrasions (from shaving), which will reduce the risk of surgical site infection.

Quality measures

Structure

a) Evidence of local arrangements to ensure that people having surgery are advised not to remove hair from the surgical site.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that people having surgery are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery.

Data source: Local data collection.

Process

a) Proportion of surgical procedures for which the person having surgery is advised not to remove hair from the surgical site.

Numerator – the number in the denominator for which the person having surgery is advised not to remove hair from the surgical site.

Denominator – the number of surgical procedures.

Data source: Local data collection.

b) Proportion of surgical procedures for which the person having surgery is advised to have (or is helped to have) a shower, bath or bed bath the day before or on the day of surgery.

Numerator – the number in the denominator for which the person having surgery is advised to have (or is helped to have) a shower, bath or bed bath the day before or on the day of surgery.

Denominator – the number of surgical procedures.

Data source: Local data collection.

Outcome

Feedback from people having surgery on whether they received the help they needed to have a shower, bath or bed bath the day before or on the day of surgery.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, social care practitioners and commissioners

Service providers ensure that systems are in place for their staff to understand and act on the need to advise people having surgery not to remove hair from the surgical site and to advise them to have (or help them to have) a shower, bath or bed bath the day before or on the day of surgery.

Healthcare professionals advise people having surgery not to remove hair from the surgical site and advise them to have (or help them to have) a shower, bath or bed bath the day before or on the day of surgery.

Social care practitioners help people to have a shower, bath or bed bath the day before or on the day of surgery.

Commissioners ensure that they commission services from service providers that can demonstrate arrangements to ensure that people having surgery are advised not to remove hair from the surgical site and advised to have (or helped to have) a shower, bath or bed bath the day before or on the day of surgery.

What the quality statement means for patients, service users and carers

People having an operation are advised not to remove hair from the area of the body where they are having the operation and are advised to have a shower or bath either the day before or on the day of the operation. If they are not able to wash themselves, they should be helped by health or social care staff.

Source guidance

Equality and diversity considerations

This quality statement applies to all people preparing for surgery, regardless of their ability to carry out personal preparations themselves. If people need help with washing before surgery or if hair removal is necessary, they should be treated with dignity at all times.

Advice should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People having surgery and their carers or parents should have access to an interpreter or advocate if needed.

Antibiotic prophylaxis

Quality statement

People having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary.

Rationale

Antibiotic prophylaxis is effective for preventing surgical site infections in certain procedures. However, the use of antibiotics for prophylaxis carries a risk of adverse effects (including Clostridium difficile-associated disease) and increased prevalence of antibiotic-resistant bacteria. The choice of antibiotic prophylaxis should cover the organisms most likely to cause infection and be influenced by the strength of the association between the antibiotic used and these adverse effects. Using a local antibiotic formulary should ensure that the most appropriate antibiotic, dose, timing of administration and duration are used for effective prophylaxis.

Quality measures

Structure

Evidence of local arrangements to ensure that people having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary and that this is recorded.

Data source: Local data collection.

Process

Proportion of surgical procedures for which antibiotic prophylaxis is indicated for which the person having surgery receives antibiotic prophylaxis in accordance with the local antibiotic formulary and that this is recorded.

Numerator – the number in the denominator for which the person having surgery receives antibiotic prophylaxis in accordance with the local antibiotic formulary and that this is recorded.

Denominator – the number of surgical procedures for which antibiotic prophylaxis is indicated.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they develop or have access to a local antibiotic formulary and that their staff understand and act on the need to prescribe and administer antibiotic prophylaxis in accordance with this to people having surgery for which antibiotic prophylaxis is indicated. This includes having systems in place to record when antibiotic prophylaxis has been given.

Healthcare professionals offer antibiotic prophylaxis to people having surgery for which antibiotic prophylaxis is indicated, in accordance with the local antibiotic formulary and record when this has been given.

Commissioners ensure development of, or access to, a local antibiotic formulary and commission services from service providers that can demonstrate arrangements to prescribe and administer antibiotic prophylaxis to people having surgery for which antibiotic prophylaxis is indicated in accordance with the local antibiotic formulary.

What the quality statement means for patients, service users and carers

People having certain types of operation for which there is a higher risk of infection are given antibiotics before surgery to help prevent infection.

Surgical site infection (NICE clinical guideline 74) also recommends that antibiotic prophylaxis should not be used routinely for clean non-prosthetic uncomplicated surgery because of the risk of adverse events, Clostridium difficile-associated disease, resistance and drug hypersensitivity [recommendation 1.2.12 (key priority for implementation)].

Patient temperature

Quality statement

Adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery.

Rationale

During surgery patients are kept in a stable condition by the operating team. All tissues heal most effectively in optimal conditions of oxygenation, perfusion and body temperature. Inadvertent perioperative hypothermia is a common but preventable complication of perioperative procedures that is associated with an increased risk of surgical site infection and other postoperative complications. Surgical patients are at risk of developing hypothermia before, during or after surgery. Maintaining normothermia throughout this period (except if cooling is required for medical reasons) will therefore reduce the risk of infection at the surgical site and ensure that patients feel comfortably warm at all times.

Quality measures

Structure

Evidence of local arrangements to ensure that adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery.

Data source: Local data collection.

Process

Proportion of surgical procedures on adults under general or regional anaesthesia in which the person having surgery has their core temperature measured and documented in accordance with Inadvertent perioperative hypothermia (NICE clinical guideline 65).

Numerator – the number in the denominator in which the person having surgery has their core temperature measured and documented in accordance with Inadvertent perioperative hypothermia (NICE clinical guideline 65).

Denominator – the number of surgical procedures on adults under general or regional anaesthesia.

Data source: Local data collection.

Outcome

Proportion of surgical procedures on adults under general or regional anaesthesia in which the person having surgery is normothermic before, during (unless active cooling is part of the procedure) and after surgery.

Numerator – the number in the denominator in which the person having surgery is normothermic before, during (unless active cooling is part of the procedure) and after surgery.

Denominator – the number of surgical procedures on adults under general or regional anaesthesia.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to measure and document core temperature in accordance with Inadvertent perioperative hypothermia (NICE clinical guideline 65) and maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.

Healthcare professionals measure and document core temperature in accordance with Inadvertent perioperative hypothermia (NICE clinical guideline 65) and maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.

Commissioners commission services from service providers that can demonstrate arrangements to ensure that they maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.

What the quality statement means for patients, service users and carers

Adults having an operation under a general anaesthetic or a regional anaesthetic (which affects a large part of the body, such as a limb or the lower half of the body) are kept comfortably warm (at normal body temperature) before, during and after the operation to help reduce the risk of infection.

This quality statement does not cover people undergoing therapeutic hypothermia or people with severe head injuries resulting in impaired temperature control. Other exclusions may apply at certain points on the perioperative pathway, such as when surgery needs to be expedited for clinical urgency. Inadvertent perioperative hypothermia (NICE clinical guideline 65) does not cover children and young people (aged less than 18 years), pregnant women or people undergoing local anaesthesia, but it is recognised that users of the quality standard may wish to consider how the quality statement on normothermia may apply to these groups.

Equality and diversity considerations

This quality statement may not apply to all pregnant women, because they are not covered by NICE clinical guideline 65. Because of the physiological changes in pregnancy, the needs of pregnant women may need to be considered separately from non-pregnant women for some types or aspects of surgery. Similarly, NICE clinical guideline 65 does not cover children (aged less than 18 years). Users of the quality standard will need to apply clinical judgement in considering how the quality statement on patient temperature applies to these groups.

Intraoperative staff practices

Quality statement

People having surgery are cared for by an operating team that minimises the transfer of microorganisms during the procedure by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

Rationale

In order to reduce the risk of surgical site infection, the risk of microbial contamination of the surgical site from the theatre environment needs to be minimised. Staff practices aimed at achieving this are known collectively as theatre discipline. In order to maintain theatre discipline, a number of practices should be followed that include using appropriate theatre wear and minimising movement of people in and out of the operating area. Effective hand decontamination will also reduce the risk of transferring microorganisms during the procedure, and this is most likely to be achieved if hand jewellery, artificial nails and nail polish are removed before decontamination takes place.

b) Evidence of local arrangements to ensure that operating teams follow practices for surgical hand decontamination in accordance with Surgical site infection (NICE clinical guideline 74) recommendations 1.3.1 and 1.3.2.

Data source: Local data collection.

c) Evidence of local arrangements to ensure that staff wear specific non-sterile theatre wear in all areas where operations are undertaken.

Data source: Local data collection.

d) Evidence of local arrangements to ensure that operating teams minimise any staff movements in and out of the operating area.

Data source: Local data collection.

e) Evidence of local arrangements to ensure that spot checks are carried out in relation to structure measures a), b), c) and d).

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that policies and procedures are in place and implemented to ensure that operating teams minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

Operating teams follow practices that minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

Commissioners commission services from service providers that have policies and procedures to ensure that operating teams follow practices that minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

What the quality statement means for patients, service users and carers

People having an operation are cared for by an operating team that minimises the chances that microorganisms will be transferred during the operation by following best practice when cleaning their hands and by wearing the correct type of clothing, and by not moving in and out of the operating area unnecessarily.

Source guidance

Definitions of terms used in this quality statement

Best practice in hand hygiene

Best practice in hand hygiene includes the following:

The operating team should remove hand jewellery, artificial nails and nail polish before operations.

The operating team should wash their hands prior to the first operation on the list using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean.

Before subsequent operations, hands should be washed using either an alcohol hand rub or an antiseptic surgical solution. If hands are soiled then they should be washed again with an antiseptic surgical solution. [NICE clinical guideline 74 recommendations 1.2.9, 1.2.10, 1.3.1 and 1.3.2.]

Best practice in theatre wear

Best practice in theatre wear includes the following:

Staff should wear specific non-sterile theatre wear (scrub suits, masks, hats and overshoes) in all areas where operations are undertaken.

Information and advice on wound care

Quality statement

People having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Rationale

Appropriate wound and dressing care promotes healing and reduces the risk of infection. Providing information and advice on this to people having surgery and their carers will reduce the risk of them doing something to the wound or dressing that might contaminate the site with microorganisms unnecessarily. If a person develops a surgical site infection, early treatment is essential to prevent the infection getting worse. Providing information on how to recognise problems with a wound and who to contact if they are concerned should lead to prompt treatment for those who need it and reduce infection-related morbidity.

Quality measures

Structure

Evidence of local arrangements to ensure that people having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Data source: Local data collection.

Process

Proportion of surgical procedures for which the person having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Numerator – the number in the denominator for which the person having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Denominator – the number of surgical procedures.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that protocols are in place to provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Healthcare professionals provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Commissioners commission services from service providers that can demonstrate that they have protocols to provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

What the quality statement means for patients, service users and carers

People having an operation and their carers are given information and advice about how to look after the wound when they go home, how to recognise problems with the wound and who to contact if they are concerned about it.

Source guidance

Equality and diversity considerations

Information should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People having surgery and their carers or parents should have access to an interpreter or advocate if needed.

Treatment of surgical site infection

Quality statement

People with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Rationale

People who develop an infection need to receive the treatment that is most likely to be effective in order to minimise associated morbidity. It is also important that they are not given more treatment than they need, because antibiotic therapy carries risks of adverse reactions, the development of resistant bacteria and Clostridium difficile-associated disease. Taking into account local resistance patterns and the results of microbiological tests will help to ensure that people receive the most appropriate treatment.

Quality measures

Structure

Evidence of local arrangements to ensure that people with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Data source: Local data collection.

Process

Proportion of surgical site infections for which the person with the infection receives treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Numerator – the number in the denominator for which the person with the infection receives treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Denominator – the number of surgical site infections.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place (including development of, or access to, a local antibiotic formulary) to offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Healthcare professionals offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected in accordance with the local antibiotic formulary and based on local resistance patterns and the results of microbiological tests.

Commissioners ensure development of, or access to, a local antibiotic formulary and that they commission services from service providers that can demonstrate that systems are in place to offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

What the quality statement means for patients, service users and carers

People with a surgical site infection are given an antibiotic that has been chosen because it is effective for the microorganisms most likely to have caused the infection. The healthcare team should look at the results of tests carried out on samples from the wound and they should also consider which antibiotics are most likely to work in the area local to the hospital, because the effectiveness of antibiotics can vary from place to place.

Surveillance

Quality statement

People having surgery are cared for by healthcare providers that monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice.

Rationale

Surveillance data on surgical site infection rates can inform and influence steps taken to minimise the risk of infection, as well helping to clearly communicate the risks to patients. Some infections take time to develop and may not become apparent until after the patient has been discharged from hospital. Therefore surveillance for infections in hospitalised patients only is likely to underestimate the true infection rate – a problem exacerbated by the increasing trend towards shorter postoperative hospital stays and day surgery. Therefore, systems that identify surgical site infection after patients leave hospital enhance the value of surveillance and the provider's ability to deliver interventions to reduce the risk of infections based on their own results, leading to continuous quality improvement.

Quality measures

Structure

a) Evidence of local arrangements to ensure the existence of surveillance systems that capture inpatient and post-discharge surgical site infections.

c) Evidence of local arrangements to ensure that surveillance data on surgical site infection rates (including post-discharge infections) are used for continuous improvement through adjustment of clinical practice.

Data source: Local data collection.

Outcome

Readmissions for surgical site infection.

Data source: Local data collection. Data collected as part of the Surgical Site Infection Surveillance Service (SSISS) are published by Public Health England in annual reports available through their website. This includes readmissions data from individual hospitals, collected as part of the Department of Health’s mandatory surveillance scheme (orthopaedic surgery).

What the quality statement means for service providers, healthcare professionals, public health practitioners and commissioners

Service providers ensure that systems are in place to monitor surgical site infection rates (including post-discharge infections) and provide feedback to their clinical and non-clinical staff and stakeholders for continuous improvement through adjustment of clinical practice.

Healthcare professionals and public health practitioners act on information provided to them on surgical site infection rates (including post-discharge infections) to adjust clinical practice for continuous improvement.

Commissioners commission services from service providers that can demonstrate that they monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice.

What the quality statement means for patients, service users and carers

People having an operation are cared for by healthcare services that monitor surgical site infection rates, share this information with patients and relevant staff, and use it to help improve services and minimise future infection rates.

Staff and stakeholders

Staff may include the board and individual clinical units in a hospital setting. Stakeholders include patients, GPs, commissioners and other local health and social care organisations [adapted from NICE public health guidance 36: quality improvement statement 3].

Quality statement

People are prescribed antibiotics in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Rationale

Antibiotic resistance poses a significant threat to public health, particularly because antibiotics underpin routine medical practice in both primary and secondary care. To help prevent the development of current and future bacterial resistance, it is important to prescribe antibiotics according to the principles of antimicrobial stewardship, such as prescribing antibiotics only when they are needed (and not for self-limiting mild infections such as colds and most coughs, sinusitis, earache and sore throats) and reviewing the continued need for them. These principles should be set out within local antibiotic guidelines and pathways and be consistent with the local antibiotic formulary. Local antibiotic formularies should indicate a range of antibiotics for managing common infections, and permit use of other antibiotics only on the advice of the microbiologist or physician responsible for the control of infectious diseases.

Quality measures

Structure

a) Evidence of local antibiotic formularies governing the use of antibiotics to ensure that people are prescribed antibiotics appropriately.

Data source: Local data collection.

b) Evidence that local antibiotic formularies are reviewed regularly.

Data source: Local data collection.

c) Evidence of local audits of the appropriateness of antibiotic prescribing.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they have antimicrobial stewardship initiatives in place, including local antibiotic formularies for antibiotic prescribing.

Healthcare professionals ensure that when they prescribe antibiotics they do so in accordance with local antibiotic formularies as part of antimicrobial stewardship.

Commissioners ensure that they commission services that have antimicrobial stewardship initiatives and in which people are prescribed antibiotics in accordance with local antibiotic formularies.

What the quality statement means for patients, service users and carers

People are offered antibiotics according to local guidance about which ones are most suitable. This includes not being offered antibiotics if they don't need them (for example, if they have a cold, a sore throat, most coughs or earache). This is to try to reduce the problem of antibiotic resistance, which is when an infection no longer responds to treatment with one or more types of antibiotic and so is more likely to spread and can become serious.

Source guidance

Definitions of terms used in this quality statement

Local antibiotic formulary

A local antibiotic formulary is a local policy document produced by a multi professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement. [Surgical site infection - full guideline (NICE clinical guideline 74)].

A local antibiotic formulary is defined as 'the output of processes to support the managed introduction, utilisation or withdrawal of healthcare treatments within a health economy, service or organisation. [Developing and updating local formularies (NICE medicines practice guideline 1)]

Local policies often limit the antibiotics that may be used to achieve reasonable economy consistent with adequate cover, and to reduce the development of resistant organisms. A policy may indicate a range of antibiotics for general use, and permit other antibiotics only on the advice of the medical microbiologist or physician responsible for the control of infectious diseases. [BNF, section 5.1]

Antimicrobial stewardship

Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. [Adapted from the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)'s antimicrobial prescribing and stewardship competencies]

The approach to prescribing in line with the principles of antimicrobial stewardship recommended for secondary care is as follows:

Do not start antibiotics without clinical evidence of bacterial infection.

If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt, effective antibiotic treatment.

Document the following on the medicines chart and in the person's medical notes: clinical indication, duration or review date, route and dose.

Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and stopping antibiotics when cultures suggest an infection is unlikely.

Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be effective.

Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first antibiotic dose and make a clear plan of action – the 'Antimicrobial Prescribing Decision'. The 5 Antimicrobial Prescribing Decision options are: Stop, Switch IV (intravenous) to Oral, Change, Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT).

Quality statement

Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.

Rationale

It is essential that organisations and agencies work together to coordinate strategies for infection prevention and control across a local area. It is equally important to share information across organisations in order to meet responsibilities for establishing the current position on infection control, monitoring the impact of quality improvement initiatives and ongoing surveillance. Leadership underpins all infection prevention and control, and is vital to ensure that this remains a priority for the organisation as a whole and each person working within it.

Quality measures

Structure

a) Evidence that the organisation includes infection prevention and control within its overall strategy.

Data source: Local data collection.

b) Evidence that the organisation's board is up to date with, and has a working knowledge and understanding of, infection prevention and control.

Data source: Local data collection.

c) Evidence that a lead for infection prevention and control has been assigned and is taking an active role.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that a strategy is in place for continuous improvement in infection prevention and control that includes accountable leadership, multi-agency working and surveillance systems.

Healthcare professionals ensure that they implement strategies for continuous improvement in infection prevention and control through accountable leadership, multi-agency working and adhering to the requirements of surveillance systems.

Commissioners ensure that they commission services from organisations that have strategies for continuous improvement in infection prevention and control that include accountable leadership, multi-agency working and surveillance systems.

What the quality statement means for patients, service users and carers

People receive healthcare from organisations that aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).

Quality statement

People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.

Rationale

Effective hand decontamination, even after wearing gloves, results in significant reductions in the carriage of potential pathogens on the hands and decreases the incidence of preventable healthcare-associated infections, leading in turn to a reduction in morbidity and mortality. Hand decontamination is considered to have a high impact on outcomes that are important to patients. Although hand hygiene has improved over recent years, remaining misconceptions about this standard principle of infection control are reported and good practice is still not universal.

Quality measures

Structure

a) Evidence of local arrangements to ensure the availability of facilities for hand decontamination.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that all healthcare workers receive training in hand decontamination.

Data source: Local data collection.

c) Evidence of local arrangements to ensure that regular local hand hygiene observation audits are undertaken.

Data source: Local data collection.

Outcome

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that healthcare workers are trained in effective hand decontamination techniques, and that handrub and handwashing facilities are available so that healthcare workers can decontaminate their hands immediately before and after every episode of direct contact or care.

Healthcare workers ensure that they are trained in effective hand decontamination techniques, and that they decontaminate their hands immediately before and after every episode of direct contact or care, even when gloves have been worn.

Commissioners ensure that they commission services in which healthcare workers are trained in effective hand decontamination techniques and decontaminate their hands immediately before and after every episode of direct contact or care, and that hand hygiene observation audits are carried out regularly.

What the quality statement means for patients, service users and carers

People receiving healthcare are looked after by healthcare workers who always clean their hands thoroughly (using handrub or soap and water), both immediately before and immediately after coming into contact with the person or carrying out care.

Source guidance

Infection: prevention and control of healthcare-associated infections in primary and community care (NICE clinical guideline 139), recommendation 1.1.2.1 (key priority for implementation).

Direct contact or care

Direct contact or care refers to 'hands on' or face-to-face contact with patients. This encompasses any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication. [NICE clinical guideline 139]

Quality statement

People who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Rationale

Catheter-associated urinary tract infections comprise a large proportion of healthcare-associated infections, and can occur whether a person has either a short-term or a long-term catheter. There is a strong association between duration of urinary catheterisation and risk of infection, and catheters are sometimes inserted inappropriately or there is a delay in removing them. This risk is greatly reduced by complying with all parts of the process for safe catheter insertion, maintenance and removal as soon as it is no longer needed. This is important in terms of both infection prevention and patient comfort and experience.

Quality measures

Structure

Evidence of a written protocol to ensure that people who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Data source: Local data collection.

Process

a) Proportion of people with a short-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Denominator – the number of people who have had a short-term urinary catheter.

Data source: Local data collection.

b) Proportion of people with a long-term urinary catheter who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed.

Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed were completed.

Denominator – the number of people who have had a long-term urinary catheter.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.

Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order to minimise the risk of infection.

Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.

What the quality statement means for patients, service users and carers

People who need a urinary catheter have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the catheter is inserted, looked after and removed correctly and safely. These procedures include things like cleaning hands, using a lubricant when inserting the catheter, emptying the drainage bag when necessary, and removing the catheter as soon as it is no longer needed. A urinary catheter is a thin flexible tube used to drain urine from the bladder.

Assessing the need for catheterisation

Catheterisation should be used only after considering alternative methods of management. The person's clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible. The need for catheterisation, as well as details about insertion, changes and care should be documented.

Hand hygiene

Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a person's catheter, and must decontaminate their hands after removing gloves.

Catheter insertion

The meatus should be cleaned before the catheter is inserted, in accordance with local guidelines or policy (for example, with sterile normal saline).

An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection.

Catheter maintenance

Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve. Healthcare workers should ensure that the connection between the catheter and the urinary drainage system is not broken, except for good clinical reasons (for example, changing the bag in line with the manufacturer's recommendations).

Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor. The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated. A separate and clean container should be used for each person. Contact between the urinary drainage tap and container should be avoided.

Urine samples must be obtained from a sampling port using an aseptic technique.

The meatus should be washed daily with soap and water as part of routine daily personal hygiene.

Quality statement

People who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Rationale

Vascular access devices are one of the main causes of healthcare-associated infections, and bloodstream infections associated with central venous device insertion are a major cause of morbidity. The risk of infection is greatly reduced by complying with all parts of the process for safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Quality measures

Structure

Evidence of a written protocol to ensure that people who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Data source: Local data collection.

Process

Proportion of people with a vascular access device who had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Numerator – the number of people in the denominator for whom all of the specified procedures were completed for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

Denominator – the number of people who have had a vascular access device.

Outcome

Incidence of vascular access device-related bloodstream infection.

Data source: Local data collection.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that systems and facilities are in place to enable staff to complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise risk of infection.

Healthcare workers ensure that they complete specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed, in order to minimise the risk of infection.

Commissioners ensure that they commission services in which specified procedures necessary for the safe insertion and maintenance of the vascular access device and its removal as soon as it is no longer needed are completed, in order to minimise the risk of infection.

What the quality statement means for patients, service users and carers

People who need a vascular access device have their risk of infection minimised by healthcare workers carrying out procedures to make sure that the device is inserted, looked after and removed correctly and safely. These procedures include things like using sterile procedures when inserting the device, using the correct antiseptics and dressings, and removing the device as soon as it is no longer needed. A vascular access device is a tube that is inserted into a main vein or artery and used to administer fluids and medication, monitor blood pressure and collect blood samples.

General asepsis

Healthcare workers must decontaminate their hands before accessing or dressing a vascular access device, using an alcohol handrub or by washing with liquid soap and water if hands are contaminated. An aseptic technique must be used for vascular access device catheter site care, when accessing the system and when administrating intravenous medication.

Skin decontamination

The skin should be decontaminated at the insertion site with 2% chlorhexidine gluconate in 70% alcohol and allowed to dry before inserting a vascular access device.

Vascular access device site care

A sterile transparent semipermeable membrane dressing should be used to cover the vascular access device insertion site. This should be changed every 7 days, or sooner if it is no longer intact or if moisture collects under the dressing.

A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used and allowed to dry when cleaning the insertion site during dressing changes.

Vascular access device management

A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone iodine) should be used to decontaminate the access port or catheter hub. The hub should be cleaned for 15 seconds and allowed to dry before accessing the system.

Preferably, a sterile 0.9% sodium chloride injection should be used to flush and lock catheter lumens.

Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 hours (whichever is sooner), or according to the manufacturer's recommendations. Administration sets used for total parenteral nutrition infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours.

Review of vascular access devices

Peripheral vascular catheter insertion sites should be inspected during every shift at a minimum, and a visual phlebitis score should be recorded.

Quality statement

People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

Rationale

Because many people with a urinary catheter, vascular access device or enteral feeding tube manage their own device or equipment, it is important that they and their family members or carers are confident about, and proficient in, infection prevention and control practices and the safe management of the device or equipment.

Quality measures

Structure

Evidence of local arrangements for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of their device or equipment, including techniques to prevent infection.

Data source: Local data collection.

Process

Proportion of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), who are educated about the safe management of their device or equipment, including techniques to prevent infection.

Numerator – the number of people in the denominator who are educated about the safe management of their device or equipment, including techniques to prevent infection.

Denominator – the number of people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate).

b) People with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), feel able to manage their device or equipment.

Data source: Local data collection using a patient survey to demonstrate that patients and carers have understood their education.

What the quality statement means for service providers, healthcare workers and commissioners

Service providers ensure that there are systems in place for people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), to be educated about the safe management of the device or equipment, including techniques to prevent infection.

Healthcare workers ensure that they educate people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), about the safe management of the device or equipment, including techniques to prevent infection.

Commissioners ensure that they commission services in which people with a urinary catheter, vascular access device or enteral feeding tube, and their family members or carers (as appropriate), are educated about the safe management of the device or equipment, including techniques to prevent infection.

What the quality statement means for patients, service users and carers

People who have a urinary catheter, a vascular access device or an enteral feeding tube, and any family members or carers who help them with this equipment, are given information and advice about how to look after the equipment safely and effectively. This includes advice about how to prevent infection. Enteral feeding is a type of feeding used for people who cannot eat normally in which liquid food is given through a tube directly into the gut.

Source guidance

Infection prevention and control of healthcare-associated infections in primary and community care (NICE clinical guideline 139), recommendations 1.2.1.1, 1.3.1.1 and 1.4.1.1 (key priority for implementation).

For people needing enteral feeding, education should cover techniques of feeding and management of the administration system. [NICE clinical guideline 139, recommendation 1.3.1.1]

Equality and diversity considerations

People with a cognitive impairment or a lack of mobility may need additional support to undertake hand decontamination and other techniques to prevent infection. Language barriers should not be a reason for not providing advice.

If religious beliefs are a source of concern in relation to the use of alcohol handrubs for hand decontamination, people could be made aware of the official views of religious bodies about the products. If information is available, people should be directed to these sources.

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Effective interventions library

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Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.

These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.

Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

An aseptic technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites. It should be used during any clinical procedure that bypasses the body's natural defences. Using the principles of asepsis minimises the spread of organisms from one person to another.

Surgery involving an incision in which no inflammation is encountered, without a break in sterile technique, and during which the respiratory tract, alimentary or genitourinary tracts are not entered.

Surgery involving an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.

Surgery involving an incision in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.

The excision or wide removal of all dead (necrotic) and damaged tissue, that may develop in a surgical wound.

'Hands on' or face-to-face contact with patients. Any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication.

An incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, there is faecal contamination, or devitalised tissue is present.

The use of handrub or handwashing to reduce the number of bacteria on the hands. In this pathway this term is interchangeable with 'hand hygiene'.

A preparation applied to the hands to reduce the number of viable microorganisms. This guidance refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol).

Occurs when a wound has been sutured after an operation and heals to leave a minimal, cosmetically acceptable scar.

Occurs when a wound is deliberately left open at the end of an operation because of excessive bacterial contamination, particularly by anaerobes or when there is a risk of devitalised tissue, which leads to infection and delayed healing. It may be sutured within a few days (delayed primary closure), or much later when the wound is clean and granulating (secondary closure), or left to complete healing naturally without the intervention of suturing.

People employed by the health service, social services, a local authority or an agency to provide care for a sick, disabled or elderly person.

Any waste produced by, and as a consequence of, healthcare activities.

Modern (post-1980) dressing materials. Designed to promote the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process.

Blood flow through tissues or organs. If not optimal, it can increase the risk of infectious complications (particularly surgical site infections).

Equipment that is intended to be worn or held by a person to protect them from risks to their health and safety while at work. Examples include gloves, aprons, and eye and face protection.